Impact Of Insurance Expansion Research Articles

The Impact of the Affordable Care Act Insurance Expansions on Opioid‐Related Emergency Department Visits

Research ObjectiveAmid rising opioid‐related deaths and hospital use, the 2010 Patient Protection and Affordable Care Act (ACA) was signed into law, with the central coverage provisions implemented in 2014. Because lack of health insurance is a barrier to opioid use disorder treatment, and because opioid use disorder treatment can prevent opioid‐related emergency department (ED) visits, we explore the impact of ACA Medicaid expansion and ACA marketplace insurance expansions on opioid‐related ED visits.Study DesignWe use ZIP Code‐level ED utilization data from the 2010–2018 Healthcare Cost and Utilization Project (HCUP) State Inpatient Databases (SID) and State Emergency Department Databases (SEDD) for 29 states, while also accounting for the implementation of relevant state‐level policies using information from sources such as the Kaiser Family Foundation and the Prescription Drug Abuse Policy System. We control for area‐level sociodemographic information using from sources such as the Bureau of Labor Statistics and the Census. We use a difference‐in‐differences (DD) estimation strategy as well as a within‐state dose–response, difference‐in‐differences‐in‐differences (DDD) model based on pre‐ACA uninsurance levels to estimate impacts of the ACA in each of the five years following the 2014 insurance expansions.Population StudiedWe use data on ED visits among nonelderly adults from 2010–2018 for 17 states that adopted Medicaid expansion on January 1, 2014 (Arizona, California, Connecticut, Hawaii, Illinois, Iowa, Kentucky, Maryland, Massachusetts, Minnesota, Nevada, New Jersey, New York, North Dakota, Ohio, Rhode Island, and Vermont) and 12 states that did not implement Medicaid expansion during the study period (Florida, Georgia, Kansas, Maine, Missouri, Nebraska, North Carolina, South Carolina, South Dakota, Tennessee, Utah, and Wisconsin).Principal FindingsWe find that ACA coverage expansions reduced opioid‐related ED visits, but the effect varies over time. Relative to non‐expansion states, opioid‐related ED visit rates in expansion states remain the same or decrease slightly in the first three years after Medicaid expansion (2014–2016). A more marked decline emerges in the fourth and fifth years (2017–2018) after Medicaid expansion. Both DD and DDD results show strong evidence that the impact of ACA insurance expansions on opioid‐related ED visits grew over time.ConclusionsWe find that ACA insurance expansions reduced opioid‐related ED visit rates, with an effect that grows over time. As time from ACA implementation increases, aggregate effects of lower out‐of‐pocket prices, improved access to care, and supply responses would most likely produce reductions in opioid‐related ED visits, which we find in the fourth and fifth year after ACA implementation. These dynamics help explain why studies examining shorter post‐ACA periods or that were unable to estimate time‐varying impacts did not detect significant impacts of coverage expansions on opioid‐related ED visits.Implications for Policy or PracticeThere are likely to be lags between the time when an individual with substance use disorder (or at risk of developing the disorder) gains coverage, the time when the individual accesses treatment, and consequent reductions in ED visits. Our findings suggest that there are similarly important dynamics in the impact of insurance expansion on opioid‐related ED visits.

Impact of Insurance Expansion on Disposition for Pediatric Trauma Patients: A National Trauma Data Bank Cohort Study

The insurance status of pediatric trauma patients is associated with access to post-discharge resources, including inpatient rehabilitation. Our goal was to understand the impact of changes in insurance coverage on access to post-acute care resources for pediatric trauma patients. We utilized the National Trauma Data Bank from 2012 to 2016 for all pediatric trauma patients with a highest body region abbreviated injury score >2. Our primary outcome was hospital discharge disposition location. We used multivariable regression to adjust for salient patient and trauma center characteristics. Additionally, we performed a sensitivity analysis including only high-volume hospitals to examine the relationship between the magnitude of facility level expansion in coverage and changes in patient disposition. We identified 195,649 pediatric trauma patients meeting inclusion criteria. From 2012 to 2016 the proportion of patients with Medicaid (35% versus 39%, P < 0.001) and private insurance (39% versus 45%, P < 0.001) increased. Increased discharges with home health (HH) (+0.6% adjusted risk difference 2012 to 2016, P < 0.001) and decreased discharges to inpatient rehabilitation and skilled nursing facilities (-0.6% adjusted risk difference 2012 to 2016, P=0.01) were associated with changes in insurance coverage. After stratifying high volume facilities by magnitude of increase in Medicaid and private insurance, we found that, for all groups, discharge to inpatient rehabilitation and skilled nursing facilities decreased (P < 0.01). Expanded insurance coverage for children was paradoxically associated with decreased discharge to inpatient rehabilitation and skilled nursing facilities after severe traumatic injury. These findings suggest that additional barriers may drive limitations in access to pediatric post-discharge services.

The Impact of Insurance Expansions on the Already Insured: The Affordable Care Act and Medicare

Some states have not adopted the Affordable Care Act (ACA) Medicaid expansions due to concerns that the expansions may impair access to care and utilization for those who are already insured. We investigate such negative spillovers using a large panel of Medicare beneficiaries. Across many subgroups and outcomes, we find no evidence that the expansions reduced utilization among Medicare beneficiaries and can rule out all but very small changes in utilization or spending. These results indicate that the expansions in Medicaid did not impair access to care or utilization for the Medicare population. (JEL G22, H51, I13, I18, I38)

Liquor store density and acute pancreatitis hospitalization

Objectives: Alcohol use is a known risk factor for acute pancreatitis, and there is a higher alcohol outlet density in areas of greater deprivation. Undetected or untreated condition with gallstones is another preventable risk factor for acute pancreatitis. This study sought to examine the rate of acute pancreatitis hospitalizations as a possible outcome of the local liquor store density and the concentration of long-term uninsured (LTU) patients.Methods: We used a universe of all inpatient visits to licensed South Carolina (SC) healthcare providers during 2012–2013 with ZIP code level covariates extracted from the American Community Survey. A loglinear regression model was used to explore environmental correlates of severe acute pancreatitis.Results: The logged liquor store density was a significant, positive predictor of the annual acute pancreatitis hospitalization rate (p = .018). Higher LTU concentration was positively associated with acute pancreatitis hospitalization rate.Conclusions: Acute pancreatitis appears to be more prevalent in areas with higher liquor store density and with higher LTU concentration. Reducing the dominance of liquor stores as the primary or only type of retail outlet is recommended. Further study is needed to examine the impact of insurance expansion on acute pancreatitis hospitalization.

133EMF Impact of Insurance Expansion on Hospital Care for the Uninsured in Maryland

133EMF Impact of Insurance Expansion on Hospital Care for the Uninsured in Maryland

Insurance Expansion and the Utilization of Inpatient Surgery: Evidence for a "Woodwork" Effect?

The impact of insurance expansion on the currently insured population is largely unknown. We examine rates of elective surgery in previously insured individuals before and after Massachusetts health care reform. Using the State Inpatient Databases for Massachusetts and 2 control states (New York and New Jersey) that did not expand coverage, we identified patients aged 69 and older who underwent surgery from January 1, 2003, through December 31, 2010. We studied 5 elective operations (knee and hip replacement, transurethral resection of prostate, inguinal hernia repair, back surgery). We examined statewide utilization rates before and after implementation of health care reform, using a difference-in-differences technique to adjust for secular trends. We also performed subgroup analyses according to race and income strata. We observed no increase in the overall rate of selected discretionary inpatient surgeries in Massachusetts versus control states for the entire population (-1.4%, P = .41), as well as among the white (-1.6%, P = .43) and low-income (-2.2%, P = .26) subgroups. We did, however, find evidence for a woodwork effect in the subgroup of nonwhite elderly patients, among whom the rate of these procedures increased by 20.5% (P = .001). Among nonwhites, the overall result reflected increased utilization of all 5 individual procedures, with statistically significant changes for knee replacement (18%, P < .01), back surgery (18%, P = .05), transurethral resection of the prostate (28%, P = .05), and hernia repair (71%, P = .03). Our findings suggest that national insurance expansion may increase the use of elective surgery among subgroups of previously insured patients.